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Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
Telehealth: a tool for the 21st century (PPT)
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Telehealth: a tool for the 21st century (PPT)

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  • 1. Telehealth: A tool for the 21 st century Karen S. Rheuban MD Professor of Pediatrics Medical Director, Telemedicine University of Virginia
  • 2. Disclosure <ul><li>I have no financial relationships to report that would create any conflict of interest in relationship to this presentation </li></ul>
  • 3. Objectives <ul><li>Understand the applications of telemedicine in the delivery of healthcare, especially as they relate to children </li></ul><ul><li>Understand statutory and regulatory issues impacting the development of telemedicine networks </li></ul>
  • 4. Definitions <ul><li>“ Telemedicine” is the use of medical information exchanged from one site to another via electronic communications to support </li></ul><ul><ul><ul><ul><li>Medical diagnosis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ongoing patient care </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Remote patient monitoring </li></ul></ul></ul></ul><ul><ul><li>“ Telehealth” encompasses a broader definition of remote healthcare that does not always involve clinical services </li></ul></ul><ul><ul><ul><ul><li>Health-related distance learning </li></ul></ul></ul></ul>
  • 5. Telemedicine: History <ul><li>Alexander Graham Bell </li></ul><ul><li>Hugo Gernsback (vision) </li></ul><ul><li>Massachusetts General </li></ul><ul><li>U of Nebraska </li></ul><ul><li>NASA </li></ul><ul><li>Dept of Defense </li></ul><ul><li>University of Virginia </li></ul>
  • 6. Mission <ul><li>Facilitate the Health System’s missions of </li></ul><ul><ul><ul><ul><ul><li>Clinical Care </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Teaching </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Research </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Public Service </li></ul></ul></ul></ul></ul>
  • 7. Services <ul><li>Videoconferencing for patient care </li></ul><ul><li>Store and forward applications </li></ul><ul><li>Distance learning </li></ul><ul><ul><ul><ul><ul><li>health professionals </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>patients </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>students </li></ul></ul></ul></ul></ul>
  • 8. UVA Specialty/Subspecialty Participants <ul><li>Cardiology </li></ul><ul><li>Dermatology </li></ul><ul><li>Diabetes </li></ul><ul><li>Emergency Medicine </li></ul><ul><li>Endocrine </li></ul><ul><li>ENT </li></ul><ul><li>Gastroenterology </li></ul><ul><li>Genetics </li></ul><ul><li>Geriatrics </li></ul><ul><li>Gynecology </li></ul><ul><li>Hematology </li></ul><ul><li>Infectious Disease </li></ul><ul><li>Nephrology </li></ul><ul><li>Neurology </li></ul><ul><li>Neurosurgery </li></ul><ul><li>Ophthalmology </li></ul><ul><li>Orthopedics </li></ul>Obesity Oncology/Tumor boards Pain management Pediatric cardiology Pediatric nephrology Pediatric oncology Plastic surgery Psychiatry Pulmonary medicine Radiology Rheumatology Surgery TCV Toxicology/Poison control Urology Wound care
  • 9. Partnerships <ul><li>Academic-community hospital linkages </li></ul><ul><li>Academic-academic hospital linkages </li></ul><ul><li>Rural clinics (FQHCs, Veteran’s clinics) </li></ul><ul><li>Virginia Department of Health </li></ul><ul><li>Virginia Department of Corrections </li></ul><ul><li>School health </li></ul><ul><li>Nursing home </li></ul><ul><li>Home telehealth </li></ul>
  • 10. Barriers to Access <ul><li>Geographic </li></ul><ul><ul><li>>20% of US population reside in rural areas </li></ul></ul><ul><ul><li>Burden of transportation to care generally borne by patients </li></ul></ul><ul><ul><li>Medicaid programs bear the burden of transportation costs </li></ul></ul><ul><ul><ul><li>1999: >$50 million/year in Virginia alone </li></ul></ul></ul><ul><ul><li>Multiple definitions of rural </li></ul></ul><ul><li>Financial </li></ul><ul><ul><li>The uninsured, underinsured (> 40 million uninsured) </li></ul></ul><ul><ul><li>Delayed access to services for uninsured </li></ul></ul><ul><ul><li>High cost of travel for locally unavailable specialty care </li></ul></ul>
  • 11. Barriers to Access <ul><li>Societal </li></ul><ul><ul><li>Societal stigmatization </li></ul></ul><ul><ul><li>Cultural barriers </li></ul></ul><ul><ul><li>Language barriers </li></ul></ul><ul><li>Maldistribution/shortage of providers </li></ul><ul><ul><li>Predicted shortage of physicians 85,000-200,000 by 2020 </li></ul></ul><ul><ul><li>Urban predominance of specialty providers </li></ul></ul><ul><ul><li>Isolation of rural health providers </li></ul></ul><ul><ul><li>Need for continuing health professional education </li></ul></ul>
  • 12. Benefits of telehealth <ul><li>Patients : </li></ul><ul><ul><li>Timely access to locally unavailable services </li></ul></ul><ul><ul><li>Spared burden and cost of transportation </li></ul></ul><ul><ul><li>Improvement in quality of care </li></ul></ul><ul><li>Health professionals </li></ul><ul><ul><li>Access to consultative services </li></ul></ul><ul><ul><li>Access to CME </li></ul></ul><ul><ul><li>Primary care oversight of patient care </li></ul></ul><ul><li>Rural communities </li></ul><ul><ul><li>Enhanced healthcare/economic empowerment </li></ul></ul>
  • 13.  
  • 14.  
  • 15. Patients served: UVA program <ul><li>>15,000 patient encounters </li></ul><ul><li>>30,000 teleradiology readings </li></ul><ul><li>Services in >30 different specialties </li></ul><ul><ul><li>Emergency </li></ul></ul><ul><ul><li>Urgent </li></ul></ul><ul><ul><li>Single consults </li></ul></ul><ul><ul><li>Block scheduled clinics </li></ul></ul><ul><ul><li>Screenings with store forward technologies </li></ul></ul><ul><ul><ul><li>New mobile digital mammography van </li></ul></ul></ul><ul><ul><ul><li>Retinopathy </li></ul></ul></ul>
  • 16. More than technology and numbers: Saving lives: Infant with Interrupted aortic arch
  • 17. More than technology and numbers: Facilitating expert care
  • 18. Enhancing access
  • 19. Educational programs <ul><li>Broadcast continuing health professional education </li></ul><ul><li>UME, GME </li></ul><ul><li>Patient education </li></ul><ul><li>School Health Projects </li></ul>
  • 20. International humanitarian outreach Swinfen Charitable Trust <ul><li>In conjunction with the Center for Online Health in Brisbane </li></ul><ul><li>Automated email consultation system </li></ul><ul><li>Physician to physician consults with attached digital images </li></ul><ul><li>Volunteer consultants in 59 subspecialties, 1479 cases </li></ul><ul><li>Consults from: </li></ul>
  • 21. Pre/perinatal care ANGELS program - Arkansas <ul><li>Antenatal Neonatal Guidelines, Education and Learning System </li></ul><ul><ul><li>University of Arkansas/Medicaid partnership </li></ul></ul><ul><ul><li>Increase prenatal screening and referrals </li></ul></ul><ul><ul><li>Genetic counseling, targeted ultrasounds, MFM consultations, pediatric consultations </li></ul></ul><ul><ul><li>Outcomes </li></ul></ul><ul><ul><ul><li>2 year period – 467 congenital malformations </li></ul></ul></ul><ul><ul><ul><li>50% referred for delivery </li></ul></ul></ul><ul><ul><ul><li>No-show rate for TM clinics 12%, UAMS 20% </li></ul></ul></ul><ul><ul><ul><li>Shannon Barringer, UAMS – Presentation Pediatric Telehealth Colloquium, 9/07 </li></ul></ul></ul>
  • 22. Tele-ophthalmology <ul><li>Tele-ophthalmology technologies: live or store forward </li></ul><ul><ul><li>Most data in patients with diabetes </li></ul></ul><ul><ul><li>Retinopathy of prematurity </li></ul></ul><ul><li>ATA: Tele-ophthalmology standards </li></ul>
  • 23. Pediatric cardiology <ul><li>Incidence of CHD is 8/1000 live births </li></ul><ul><li>Traditional models of care: </li></ul><ul><ul><li>Schedule appointment </li></ul></ul><ul><ul><li>Emergency transfer </li></ul></ul><ul><ul><li>Wait for field clinic </li></ul></ul><ul><ul><li>Obtain echo and mail, courier </li></ul></ul><ul><li>Models for tele-echocardiography </li></ul><ul><ul><li>Live interactive support of remotely located technologists </li></ul></ul><ul><ul><li>Store forward images sent in digital format </li></ul></ul>
  • 24. Acute stroke intervention <ul><li>Challenge of lack of access to stroke neurologist in rural areas </li></ul><ul><li>Time is of the essence (3 hour window for thrombolytic agents </li></ul><ul><li>Increase use of TPA in rural hospitals from 4% to 23% </li></ul>
  • 25. HIV/AIDS <ul><ul><li>Outcomes: UVA Telehealth HIV Program 1 </li></ul></ul><ul><ul><ul><li>213 correctional patients treated with 1812 visits over 5 year period </li></ul></ul></ul><ul><ul><ul><li>Of patients naïve to therapy: </li></ul></ul></ul><ul><ul><ul><ul><li>77% attained undetectable viral load (<50 copies/ml) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>50-60% in HIV clinic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>40% receiving community based care by non-HIV specialists </li></ul></ul></ul></ul><ul><ul><li>1 Rheuban,KS, Wispelwey B et al HIV/AIDS, HRSA Telemedicine Technical Assistance Documents 2004 </li></ul></ul>
  • 26. Cancer outreach: Mobile digital mammography
  • 27. Tele-pathology <ul><li>Primary interpretation </li></ul><ul><li>Second opinion </li></ul><ul><li>Collaborative tumor boards </li></ul><ul><li>Remote access to clinical trials </li></ul>
  • 28. Tele-mental health <ul><li>Shortage of mental health providers in rural areas </li></ul><ul><li>Consultations, medication management </li></ul><ul><li>Sign language for hearing impaired </li></ul><ul><li>Interpreter services </li></ul>
  • 29. Tele-mental health <ul><li>Comprehensive review of the medical literature in telepsychiatry 1 </li></ul><ul><ul><li>Technology predominantly interactive videoconferencing </li></ul></ul><ul><ul><li>Improve access, shorter wait times </li></ul></ul><ul><ul><li>High rates of patient satisfaction in all age groups </li></ul></ul><ul><ul><li>Diagnosis change from PC provider diagnosis in 91% </li></ul></ul><ul><ul><li>Medication changes in 57% </li></ul></ul><ul><ul><li>Reduced geriatric hospital admissions from long-term care facility by 59% </li></ul></ul><ul><ul><li>1 Hilty, D, et al, Can J Psych 2004; 49:12-23 </li></ul></ul>
  • 30. e-ICU <ul><li>Models for support of intensive care units 1 </li></ul><ul><ul><li>Two adult ICUs in large tertiary care hospital system </li></ul></ul><ul><ul><li>2140 patients receiving ICU care </li></ul></ul><ul><ul><li>E-ICU services from 12 noon – 7am </li></ul></ul><ul><ul><li>Program utilized off-site intensivists, physician extenders, electronic data display, decision support tools </li></ul></ul><ul><ul><li>Results: </li></ul></ul><ul><ul><li>Hospital mortality decreased from 12.9-9.4% </li></ul></ul><ul><ul><li>ICU length of stay shorter 4.35-3.63 days </li></ul></ul><ul><ul><li>1 Breslow, MJ, Crit Care Med 2004 32(1): 31-38 </li></ul></ul>
  • 31. Remote monitoring and Home telehealth <ul><ul><ul><ul><li>Remote monitoring </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CHF </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Diabetes </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>COPD/ Asthma </li></ul></ul></ul></ul></ul>
  • 32. Challenges <ul><li>Funding of telehealth (Stark, Anti-kickback Laws) </li></ul><ul><li>Reimbursement </li></ul><ul><li>Outcomes </li></ul><ul><li>Confidentiality </li></ul><ul><li>JCAHO </li></ul><ul><li>Licensure </li></ul><ul><li>Malpractice </li></ul><ul><li>Telecommunications venue/costs </li></ul><ul><li>Integration with EMRS/RHIOS </li></ul><ul><li>Interagency alignment related to policies </li></ul><ul><ul><li>Federal (definition of rural, rural vs urban) </li></ul></ul><ul><ul><li>State (eligible plans, coverage of store and forward) </li></ul></ul>
  • 33. Outcomes:2006 Agency for Healthcare Research and Quality (AHRQ) <ul><ul><li>Still significant gaps in the evidence base between where telemedicine is used and where its use is supported by high-quality evidence. </li></ul></ul><ul><ul><li>Further well-designed and targeted research that provides high-quality data will provide a strong contribution to understanding how best to deploy technological resources in health care. </li></ul></ul>Hersh, W, Supplement. Telemedicine for the Medicare Population: AHRQ Evidence Report/Technology Assessment Number 24, Supplement, 2006
  • 34. Virginia Telehealth Network <ul><li>Multi-institution/organization collaboration initiated by Virginia Department of Health </li></ul><ul><li>Inventory current activities </li></ul><ul><li>Increase awareness of telehealth </li></ul><ul><li>Increase collaboration </li></ul><ul><li>Secure funding – competitive grants, appropriations </li></ul><ul><li>Advocate in support of critical policy issues </li></ul>
  • 35. The future of telehealth <ul><li>Outcomes </li></ul><ul><li>Standards </li></ul><ul><li>Demonstration projects (ARRA) </li></ul><ul><li>Integration into mainstream medicine </li></ul><ul><li>Collaboration amongst providers, policymakers, regulators </li></ul><ul><li>Champions at all levels </li></ul><ul><li>Engage your legislators!!! </li></ul>
  • 36. Champions Congressman Rick Boucher, Mrs. Lisa Hubbard, Alexandra Bartley
  • 37.  

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